In the United States, national, state and local HIV organizations are in various stages of mobilizing campaigns to make reducing new HIV infections and achieving viral suppression among people living with HIV (PLWH) the highest priority in order to accelerate the end of the HIV epidemic. NASTAD, the National Alliance of State and Territorial AIDS Directors, is coordinating with many of these efforts and believes that U.S. communities and government must work synergistically toward one common goal: transitioning to an era in which new HIV infections are epidemiologically rare among all populations in every zip code in America.
For the first time in history, we have scientifically validated and effective prevention and care modalities "showing us" that ending the HIV epidemic is feasible. Make no mistake, there is heavy lifting to do, including reimagining how we work together across siloes and institutions. In many communities, there are often significant political, financial, cultural and other hurdles to overcome. With enough patience, passion, strategy and resources, these obstacles can be overcome.
But we can't get to this new era without addressing the unacceptable health disparities that exist among key populations. These disparities are by-products of systems, practices, institutions and policies that fail individuals and communities. To accelerate achieving health equity, we must think beyond HIV care and prevention and include other life essentials: stable housing, food and nutrition, stable incomes and job security. Ever paramount is our collective role in calling out and addressing stigma, discrimination, criminalization, racism, transphobia and all the phobias and "isms" that we know block our pathway to success.
In a few weeks at NASTAD's 25th annual meeting, we will launch the first Chair's Challenge, during which our incoming board chair, DeAnn Gruber from Louisiana, will challenge health departments across the country to work with their cities, PLWH and communities to come together, if they have not done so already, and begin, release and implement right-sized plans to end the epidemic. Some jurisdictions are models for such plans, including New York (New York City and New York state), Washington state, Colorado (Denver and state of Colorado), and San Francisco. Others have already begun processes to release and implement plans. We will push for bold actions, targets and rigorous implementation plans that have at their core reducing new HIV infections and achieving viral suppression among PLWH.
Modeled after the notable efforts of jurisdictions engaged in more advanced steps to end the epidemic and in concert with the National HIV/AIDS Strategy, updated to 2020, NASTAD has developed a preliminary set of actions that states and communities should implement as part of their strategies. While not exhaustive, these recommended actions have the potential to produce the biggest impact in ending HIV transmission in local jurisdictions. NASTAD expects that these recommendations will help inform public health and community efforts to develop blueprints, roadmaps and/or statewide plans to end the epidemic:
- Get People Covered and Improve Health: We must educate communities about their health insurance options and expand coverage for vulnerable populations. All of our systems of care for PLWH and vulnerable populations should have as their cornerstone ensuring that people are enrolled in health care coverage. This is an essential foundation on which the steps below can be achieved. The other critical foundation for health care coverage is Medicaid expansion in every state!
- Scale-Up Testing: Policy-makers, public health practitioners, clinicians and insurers must take new, bold actions to routinize HIV testing. While most jurisdictions have eliminated requirements of written informed consent for HIV testing, HIV testing is still not a standard medical practice. We must focus on strategies to support uptake of HIV testing that identify early infection and facilitate linkages to care. This may mean changing older strategies that target only certain populations or venues with historically higher positivity rates. Testing and linkage must be implemented in myriad venues such as community-based organizations (CBOs) and clinical settings including emergency departments, primary and urgent care settings and correctional facilities. And, we must expand targeted HIV testing to gay men and other men who have sex with men (MSM) of color and people who use drugs. Moreover, if we're going to truly bring testing and linkages to care to scale, programs and practices must be culturally responsive.
- Scale-Up Treatment: To improve viral suppression rates among PLWH, we must strengthen laboratory reporting and use of data to ensure that individuals are linked to and reengaged and retained in life-sustaining care, increase insurance coverage of PLWH, and provide incentives for performance to benefit patients and providers. Moreover, to help sustain viral suppression, we must support non-medical service needs for PLWH by streamlining access to vital supportive services, including employment, housing, drug user health services and substance use/mental health treatment. Helping people attain viral suppression means engaging them in the health care system. In order to do that, we must work with PLWH, faith leaders, CBOs and policymakers as never before to ensure that we can reduce stigma and remedy structural inequalities in our systems of care.
- Scale-Up PrEP: We must educate providers and people who are most vulnerable for HIV infection about pre-exposure prophylaxis (PrEP), leverage payment and reimbursement for PrEP and push for its availability by expanding the range and types of facilities that provide PrEP services. We must urge policymakers and other payers (i.e., federal, state and local government, as well as private) to provide funding for PrEP services.
- Commit to Addressing Health Inequities: To really bring an end to HIV transmission, we must reframe our public health approaches and interventions to include social justice action and intentionally deepen our understanding of the needs of the most vulnerable communities. That means removing discriminatory practices within our public health systems and boldly demonstrating through action that the lives of our most vulnerable communities really do matter.
Over the coming months, NASTAD will increase our efforts to support governmental public health by collaborating with national, state, local and community partners to scale-up initiatives to end the epidemic. Moving forward, we seek rigorous input, ideas and action! And our collective work must combat the very real socio-economic, political and racial disparities impacting communities. Let's forge ahead in partnership -- governmental public health, PLWH, researchers, advocates, community and policymakers -- to bring an end to new HIV infections and improve the quality of life for people living with HIV.
Murray Penner is an HIV and hepatitis treatment and drug pricing expert who has been living with HIV since 1986. Murray is also the executive director at NASTAD. NASTAD is a non-profit national association that represents public health officials who administer HIV and hepatitis health care, prevention, education and supportive service programs funded by state and federal governments in all 50 U.S. states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the U.S. Pacific Islands. NASTAD also supports partner governments in Africa, the Central America region and the Caribbean region.